Provider Demographics
NPI:1477649499
Name:VANOTTEREN, DAVID GORDON (OD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:GORDON
Last Name:VANOTTEREN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8850 SALINE MILAN RD
Mailing Address - Street 2:
Mailing Address - City:SALINE
Mailing Address - State:MI
Mailing Address - Zip Code:48176-8826
Mailing Address - Country:US
Mailing Address - Phone:734-944-4404
Mailing Address - Fax:734-944-3937
Practice Address - Street 1:1601 E US HIGHWAY 223
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-4454
Practice Address - Country:US
Practice Address - Phone:517-265-9883
Practice Address - Fax:517-265-9796
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003594152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION30050-001Medicare ID - Type Unspecified
MIU31683Medicare UPIN